What is a pathology report?
A pathology report describes cells and tissues from a microscopic level to make a diagnosis of a disease. A report will provide a diagnosis based on a tissue sample, most often taken during a biopsy. The diagnosis will reveal if the tumor is benign or malignant and other additional information, such as a stage or grade of a cancer.
These reports can be confusing to read because of the complicated medical terminology, especially if your physician does not take time to explain the reports. Even if your physician does explain the reports, it is still important to have an understanding of what information a pathology report provides and what information a pathologist is seeking.
A pathology report is made up of the following parts:
Demographics: patient information.
Specimen: origin of tissue samples.
Clinical history: medical history of patient as it relates to the tissue sample.
Clinical diagnosis: doctor’s diagnosis prior to the diagnosis of the pathologist.
Procedure: the way in which the tissue sample was removed (i.e., type of biopsy or surgery).
Gross description: the macroscopic description of the color, weight, and size of the tissue as seen by the naked eye.
Microscopic description: the description of the tissue sample as seen by the pathologist under the microscope and how it compares with normal cells — the following are described:
- Cell structure: grade and type of tumor.
- Tumor margins: “positive” or “involved” if cancer cells are present; “negative” or “not involved” if cancer cells are not present; “close margins” if cells are neither “positive” or “negative.”
- Vascular invasion: whether blood vessels are present within the tumor.
- Depth of invasion: how much the tumor has spread.
- Pathologic stage: describes the extent of the tumor, node invasion, and metastasis in strict coherence to the pathology report and NOT the clinical report.
Special tests or markers: other tests performed on the tissue sample to find specific proteins or genes.
Diagnosis: summary of final diagnosis that includes the type of tumor and cell of origin.
Pathologist signature: pathologist who studied the tissue sample and prepared the report.
Make sure to ask your doctor to go over the report with you if you have any questions.
ä ON THE INTERNET:
Pathology reports – NCI:
Understanding your Pathology report – ASCO’s Cancer.net:
For more information, contact Courtney Britton, librarian at Cancer Services of Greater Baton Rouge, at (225) 927-2273, cbritton@cancerservices
.org, or visit the Resource Center at 550 Lobdell Ave., Baton Rouge. This column is presented as a service by Cancer Services of Greater Baton Rouge, a United Way affiliate.